Board of Health Ice Rink Inspection Sheet - Mass.Gov

Board of Health Ice Rink Inspection Sheet
Date of Inspection: __________Inspection Conducted by:___________________________
Rink Information
Name of Rink: _____________________________________________________
Street:____________________________________________________________
City: __________________________________________State: MA
Zip Code: __________________________
Contact: __________________________________________________________
Telephone Number: ___________________ Fax Number: ________________________
Record Keeping Log
Is a Record Keeping Log kept by the rink? Y N
Is the following information kept in this log? (Circle Y for yes, N for No or
enter information)
Ice Resurfacing Equipment
Brand of ice resurfacer Y N
Age of resurfacer Y N
Fuel type:
Gasoline Propane
Natural Gas
Dates of tuning: Y N
Name, company and address of person
performing the tuning Y N
Name, company and address of person
performing repairs of maintenance
on the ice resurfacer Y N
Manufacturer, type and date of installation
of a catalytic converter Y N
Name, company and address of person installing
or performing maintenance of the catalytic converter Y N

Air Sampling Information
Date, location and time of every sample
of carbon monoxide or nitrogen dioxide Y N
Results of air sampling in parts per
million (ppm) for carbon monoxide and
nitrogen dioxide Y N
Name of sampling devices Y N
Method for sampling carbon monoxide
Method for sampling carbon monoxide
colorimetric
hand-held monitor
in place chemical
sensor
computer chip
colorimetric
computer chip
Signature of person performing the air sampling Y N
Description of correction measures taken
for air levels above correction levels Y N
Results of carbon monoxide and nitrogen
dioxide after correction measure
implemented Y N
Date of last calibration and name of person
performing the calibration Y N
Lot numbers of colorimetric tubes or computer
chip sampling devices Y N
Resurfacer Schedule
Number of resurfacing prior to inspection, that day? _________
Number of resurfacings per day:
Mon___ Tues___ Wed___ Thur___ Fri___ Sat___ Sun___
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Type of Ventilation
Supply On Off Capacity (CFM)________________
Exhaust On Off Capacity (CFM)________________
Size of Rink
Square feet: _____________
Ceiling height: ___________
Indoor Air Test Results for Skating Rinks
Sample Date Time Carbon Monoxide
* ppm
Outside
Ambient Air
20 Minutes
After Resurface
40 Minutes
After Resurface
60 Minutes
After Resurface
Immediately After
Resurface
20 Minutes
After Resurface
40 Minutes
After Resurface
60 Minutes
After Resurface
*ppm = parts per million of air
Nitrogen Dioxide
* ppm
Air Sample
Device
Remarks
Indoor Air Levels for Carbon Monoxide and Nitrogen Dioxide
If an air sample exceeds 30 ppm for carbon monoxide or 0.5 ppm for nitrogen dioxide, the rink must take
positive measures to decrease air concentrations of these contaminants below these standards.
If an air sample exceeds 60 ppm for carbon monoxide or 1 ppm for nitrogen dioxide, the rink must notify the
local fire department, local board of health and the Bureau of Environmental Health Assessment within 24 hours
of sampling..
If an air sample exceeds 125 ppm for carbon monoxide or 2 ppm for nitrogen dioxide, EVACUATE THE
RINK, notify the local fire department, local board of health and the Bureau of Environmental Health
Assessment.
The Bureau of Environmental Health Assessment can be contacted at (617) 624-5757 during work hours, or at
(617) 522-3700 during the night or weekend.
Form:ice4/(amended 2000)
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